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This finding indicates congenital partial absence of the vas deferens, and these patients should be tested for cystic fibrosis mutations (see Chapter 24). After it travels between the crus and the pubis, the dorsal artery of the penis supplies the dorsal surfaces of the corporeal bodies. Effects of vardenafil administration on intravaginal ejaculatory latency time in men with lifelong premature ejaculation. Many transgender persons report a history of discrimination from both the general public and from health care providers, so it is critically important to establish sensitive rapport early when interacting with transgender patients (Makadon, 2011). The factors that contribute to success of internal urethrotomy have been defined as follows: internal urethrotomy should be reserved for strictures of the bulbous urethra; the stricture should be less than 1. Chapter30 SurgeryforErectileDysfunction 721 significantly reduced the rates of infection and other complications, and innovations in prosthetic design have had a positive impact on device malfunction rates. Priapism secondary to penile metastasis: a report of two cases and a review of the literature. Although the simplicity of these study designs is elegant, multiple factors are involved in sexual arousal-especially when triggered by visual clues. Comparison of puncture versus vasotomy techniques for vasography in an animal model. If the scrotum cannot be closed, a meshed split-thickness skin graft is used to cover the testes, as described previously. Patients usually have normal erectile function after subclinical or clinical fracture of the penis; there does not appear to be an association with concomitant global cavernosal veno-occlusive dysfunction. Receptor studies show that only 10% of adrenoceptors in the penile tissue are of the type, and their stimulation is thought to mediate relaxation (Andersson and Wagner, 1995). Thoracic metastasis in the absence of retroperitoneal disease and/or elevated serum tumor markers is uncommon, particularly for seminomas. A thorough review of 46 such tumors from the Armed Forces Institute of Pathology revealed an equal number of benign and malignant lesions (Dehner and Smith, 1970). The lesion of a subclinical fracture of the penis is believed to be due to the disruption of the outer longitudinal layer of the tunica albuginea during the buckling trauma. In a comprehensive literature review, Traish and colleagues (2009) noted that low testosterone precedes elevated fasting insulin, glucose, and hemoglobin A1c values in men who develop diabetes, suggesting that hypogonadism may be a sentinel event in the development of diabetes. GenitalBurns the ability to reconstruct the damage caused by genital burns often depends on how well the normal structures have been maintained after the acute injury. Because the trauma that results in acquired curvature is virtually always associated with intercourse, the occurrence of acquired curvature is nil before the onset of puberty. Use of selective embolization of the bilateral cavernous arteries for post-traumatic arterial priapism. In children who develop priapism after straddle trauma, every effort should be made to localize the arteriolar-sinusoidal fistula. We close the corporeal bodies with 4-0 or 5-0 polydioxanone suture, widely spatulate the urethral meatus, and immediately cover the penile shaft with a split-thickness skin graft. Radiation-based strategies are discussed later in the section on radiation therapy for the primary lesion. There is a great deal of heterogeneity among self-identified sex therapists so it is beneficial to establish a working relationship with one or more established therapists who have extensive experience and/or training in sexual health issues. Lymphadenectomy We advocate removal of the left common iliac, para-aortic, preaortic, interaortocaval, and medial paracaval lymph nodes. Types 16, 18, 31, 33, 35, and 39 have a higher association with malignant disease (Smotkin, 1989). Penile erection has been induced in vivo with eretina by direct intraperitoneal injection with a minimum effective dose of 0. Brain centers activated in orgasm include the medial amygdala, the anterior cingulate, the frontal, parietal, and insular cortices, and the cerebellum (Komisaruk et al, 2004). After inspection of the vulva and labia majora, the labia minora, clitoris, and vulvar vestibule should be examined. Clinical outcome of 36 male patients with primary urethral carcinoma: a single center experience. Further investigation is needed to establish the relationship of volumetric changes and the rigidity of the penis. Microsurgical vasovasostomy: the microdot technique of precision suture placement.

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After intraperitoneal access is achieved (via a Veress needle or Hasson technique), four equally spaced, 10/12-mm laparoscopic ports are placed in the midline beginning 1 cm below the xiphoid process. Further investigation was encouraged but took years owing to absence of industry support. Less commonly noted complications of internal urethrotomy include bleeding (almost always associated with erections immediately after the procedure) and extravasation of irrigation fluid into the perispongiosal tissues. Relationship between the duration of sexual abstinence and semen quality: analysis of 9,489 semen samples. As mentioned earlier, -adrenergic sympathetic nerves mediate both bladder neck closure and emission. Population-based data reveal that although neonatal circumcision is highly protective for invasive penile cancer, it does not afford the same level of protection for carcinoma in situ. Elegant studies of early metastasis demonstrated the drainage pattern of the testes. Congenital curvatures of the penis can be categorized as chordee without hypospadias or congenital curvature of the penis. Previously it was noted that approximately 85% of urethral carcinoma cases occur in white women (Terry et al, 1997); however, Swartz and col leagues (2006) reported a greater incidence of primary urethral cancers in AfricanAmerican women than in white women. Imiquimod is an immune modulator that enhances natural killer cell activity (Buechner, 2002; Sanchez-Ortiz and Pettaway, 2003). Estrogen and progestogen use in postmenopausal women: July 2008 position statement of the North American Menopause Society. Patients with inguinal nodal metastases are at increased risk for spread to the pelvic nodes. All discussion of sexual matters is done privately and confidentially, and the clinician is required to express trust and concern as well as a nonjudgmental manner that epitomizes the doctor-patient relationship. Treatment Although the treatment of urethral stricture disease dates to the foundations of urology, significant progress made during the last 50 years allows many of the most complex strictures to be reliably reconstructed in one stage. The glands of the central zone are thought to be of wolffian duct origin, as they differ immunohistochemically and structurally from the other glands of the prostate (McNeal, 1988). In the distal two thirds of the penile shaft, the circumflex veins from the corpus spongiosum course around the corpora cavernosa to enter the deep dorsal vein perpendicularly. For the elderly in whom sexual function is not an issue, partial penectomy may be quite acceptable, offering a prompt and effective treatment with relatively few side effects limiting activity in the postoperative period. Among 5 patients exhibiting an objective response, 3 were alive and disease free at 48, 50, and 73 months. Many provide insight into the biologic processes involved in reproduction, but similarly designed studies report conflicting results when these assays are applied to clinical problems. The presence and extent of patient, partner, or interpersonal related negative psychological consequences such as bother, distress, frustration, or the avoidance of sexual contact should be established. Poor candidates for this treatment include those with extensive calcification, curvature of greater than 90 degrees, or ventral curvature, in which it is difficult to adequately infiltrate the plaque (Levine et al, 2002). Loss of compliance of the penile sinusoids associated with increased deposition of collagen and decreased elastic fiber may be seen in diabetes, hypercholesterolemia, vascular disease, penile injury, or old age. The postcoital test, also known as the Sims-Huhner test, assesses sperm interaction with mucus in two parts: first, it appraises mucus characteristics favorable to sperm penetration; and second, it gauges the number and motility of observed sperm (Griffith and Grimes, 1990). A variety of treatments for genital warts are available, but none has been proven to reduce transmission to sexual partners nor to prevent progression to dysplasia or cancer. Whereas histologically this condition is a carcinoma in situ, the clinical course of bowenoid papulosis is invariably benign (Su and Shipley, 1997). The tumor is not unusual in younger men; in one large series, 22% of patients were younger than 40 years and 7% were younger than 30 years (Dean, 1935); the disease has also been reported in children (Kini, 1944; Narasimharao et al, 1985). In males, the gonadal veins (testicular veins) receive drainage from the pampiniform plexus, which is the venous complex that emerges from the testes. This term implies that although the meatus is not improperly placed, curvature is due to inappropriate fetal development of the ventral penile structures. Variations in the initial technique have been used to reduce false-negative rates (Kroon et al, 2004).

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Varicoceles are found in approximately 35% of men with primary infertility but 75% to 81% of men with secondary infertility. In the second study, Menard and associates (2011) examined surgical complication and patient satisfaction rates in subjects receiving a penile implant after radical prostatectomy and found that the procedure was associated with low morbidity and high satisfaction, especially with respect to erectile function; however, they noted that fibrosis in the retropubic space may necessitate a second incision for reservoir placement or use of a two-piece device instead of a three-piece device. Microsurgical approaches allow accurate approximation of the vasal mucosa to that of a single epididymal tubule (Silber, 1978), resulting in marked improvement in the patency and pregnancy rates (Schlegel and Goldstein, 1993; Chan et al, 2005). Both groups have noted that the literature on priapism is composed mainly of small case series and individual case reports and includes inconsistent definitions and methodologies with few long-term erectile function outcome data. Another theoretical advantage would be a decrease in the risk of erectile dysfunction and potential decreased risk for erosion if subsequent artificial sphincter implantation were probable. Reduction in testosterone levels might be caused by a reduced number of Leydig cells or by reduced androgenic activity of the cells. Efficacy and safety of a testosterone patch for the treatment of hypoactive sexual desire disorder in surgically menopausal women: a randomized, placebo-controlled trial. An aortic tube graft is most commonly used for reconstruction; however, an aortobi-iliac graft may be used depending on the extent of tumor involvement. The risk of teratoma at metastatic sites is generally not a consideration for advanced seminoma, which has important implications for the management of residual masses after chemotherapy. This is in contradistinction to those who had less severe calcification of grade 1 (<0. Side effects occurring in 2% or more of patients include headache, flushing, dyspepsia, rhinitis, light sensitivity, and myalgia. They identified a sentinel node in 98% of patients, for a sensitivity rate of 82% and a false-negative rate of 18% (6 patients). Lymphatics Lymph drainage from the glans penis collects in large trunks in the area of the frenulum. If only the foreskin is involved, circumcision may be curative (Akporiaye et al, 1997). The Boston Area Community Health Study reported a lower odds ratio for sexual issues in women of black race compared to Latino and white women (Rosen et al, 2009a). Stimulatory or inhibitory messages can be relayed to the spinal erection centers to assist or inhibit erection. In the high-power view demonstrated in panel B, the arrow indicates the typical triangular shape of a mature sperm head. The test of heart rate control (mainly parasympathetic) consists of measuring heart rate variations during quiet breathing, deep breathing, and in response to raising the feet. Anorgasmia from clomipramine in obsessive-compulsive disorder: a controlled trial. These findings corroborate the notion that the cerebellum plays an important role in emotional processing. Increased quantities of blood products should be considered for patients requiring more complex resections. The catheter can be removed the morning after the surgery by the patient at home, and the stitches are removed after 14 days. The "long side" is plicated without the need for excision; however, the plication is durable in that the tunica is opened and closed with a resulting scar, rather than reliance only on the strength of sutures as originally described by Nesbit (1965). Alpha and beta sympathetic responses to isoproterenol by the isolated rat vas deferens. Smaller hemangiomas are generally treated with transurethral fulguration or laser; however, recurrent bleeding as a result of inadequate abla tion may occur. Patients undergo a mechanical bowel preparation the afternoon before surgery and take only clear liquids until midnight to decompress the bowels. In a similar study, Hilton and associates (1997) reported sensitivity and specificity of 93% and 58%, respectively, using a cutoff of 4 mm for lymph nodes in the primary landing zone that were anterior to a horizontal line bisecting the aorta.

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Table 37-10 provides a guideline for more intensive follow-up of high-risk patients, especially within the first 2 years. Sertoli cell tumors of the testis, not otherwise specified: a clinicopathologic analysis of 60 cases. Localization of sperm during microdissection testicular sperm extraction in men with nonobstructive azoospermia. False-negative results may occur in aging patients and in patients with depression or anxiety, which may conditionally affect the physiology of sleep-related erectile phenomena. If so, replantation by the technique described by McRoberts and colleagues (1968) should be carried out. Occasionally, a patient or his primary care physician ignores the stigmata of the trauma (often described as "minimal" by patients), and the patient presents with a noticeable lateral scar that causes indentation of the lateral aspect of the penis and, in some cases, curvature. It appears as a cutaneous neovascular lesion, a raised, painful, bleeding papule or ulcer with bluish discoloration. The fossa navicularis is contained within the spongy erectile tissue of the glans penis and terminates at the junction of the urethral epithelium with the skin of the glans. An increased incidence of penile intraepithelial neoplasia has been found in the male partners of women with cervical intraepithelial neoplasia (Barrasso et al, 1987; Iversen et al, 1997). Lifelong monitoring of these patients for the secondary effects of inflammation is necessary. The surgeon must be guided by familiarity with various techniques: percutaneous shunting, open distal shunting, proximal shunting, and vein shunting. Routine cardiac assessment is not necessary for all patients with erectile dysfunction. Hormonal contraceptives (oral, subcutaneous, injectable) modulate E to prevent ovulation. The test has been questioned as having poor discriminatory value of response latencies (Pickard et al, 1994). These fibers are positive for cholinergic and nitrergic neurons (Yucel and Baskin, 2004). A sarcoma has been reported to masquerade as a Peyronie plaque (Moore et al, 1975). Psychological correlates of sexual dysfunction in female rectal and anal cancer survivors: analysis of baseline intervention data. Corporal Burnett "Snake" surgical maneuver for the treatment of ischemic priapism: long-term followup. If, however, there are no sperm within the epididymal tubules, the patient is either obstructed above the level of the epididymal biopsy site or has primary seminiferous tubular failure and no harm has been done. The gubernaculum is inspected for the presence of veins exiting from the tunica vaginalis. In genitourinary reconstructive surgical procedures, we tend to use the term island flap. However, Chaux and colleagues (2009) questioned these findings as they examined 117 specimens among patients undergoing primary tumor therapy and lymph node dissection. These effects are likely driven by enhancement of earlier phases of sexual response and no study groups have investigated hormone manipulations with a primary end point of orgasm. The literature fails to define accurately what the surgeon can expect regarding physical characteristics (Jordan, 1993). Patency of ejaculatory ducts after transurethral resection of ejaculatory ducts verified by reflux seen on voiding cystourethrogram. Damage to the device is avoided by passing both sutures and Keith needle before placing a cylinder into a corpora (Bettocchi et al, 2010). Penile biopsies showed malignant peripheral nerve sheath tumor or neurofibrosarcoma. A study with a mean follow-up of 7 years included 87 patients with clinical stage I disease and revealed a 9% and 0% relapse rate for patients with pN0 and pN+ disease, respectively, with all patients alive and free of disease at last follow-up (Cresswell et al, 2008). A comparison of the roles of surgery and radiation therapy in the management of carcinoma of the female urethra. Buccal: alterations in taste and examination of gum and oral mucosa for irritation Injectable: fluctuations in symptom, fluid retention Testosterone patches: irritation at the application site Testosterone gels: Advise patient to cover the application sites with clothing, local hygiene before skintoskin contact with women or child.

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Diagnostic Delay Diagnostic delay is a well-recognized phenomenon of this disease, with patients and physicians contributing to this delay. Review of penile prosthetic reservoir: complications and presentation of a modified reservoir placement technique. They have a significant impact on sexual fulfilment for both the man and his partner and may result in infertility. Relations between the fertilizing ability, motility and metabolism of epididymal spermatozoa. To correct a distal perforation, the damaged corpus apex should first be exposed through a transverse incision of the skin and tunica albuginea near the glans. Induction chemotherapy is favored in patients with a high risk of occult metastatic disease on the basis of elevated serum tumor markers after orchiectomy and/or bulky (>3 cm) retroperitoneal lymphadenopathy. Preoperative penile length and degree and direction of curvature deformity appear to correlate with postoperative satisfaction (Mulhall et al, 2005; Greenfield et al, 2006). Toxicity was acceptable and no treatment-related deaths occurred (Pagliaro et al, 2010). The arterial branches within the epididymis enter along septa formed from the connective tissue sheath. Sexual function in men older than 50 years of age: results from the health professionals follow-up study. A Medical Research Council randomized trial of single agent carboplatin versus etoposide and cisplatin for advanced metastatic seminoma. There are significant variations among assay techniques and among different laboratories. The dorsal nerve of the clitoris is the principal somatic sensory innervation of the clitoris and surrounding tissues. Factors affecting impairment and recovery of testicular function after cytotoxic therapy include the agent used, the dose received, and the maturation of testis at the time of insult (Pryzant et al, 1993). Approximation of the anterior vaginal wall and labia may help prevent urinary incontinence, although a sling procedure or other procedure to treat urinary incontinence may need to be subsequently performed. Decreased sexual sensation has been examined and reported on infrequently, but it does appear that around 20% of men will describe some reduction in penile sensitivity, rarely interfering with orgasm or ejaculation. Such superficial disease may now be treated more appropriately with laser or organ-sparing surgical techniques. Persistent high-volume chylous drainage (>100 mL/24 hr) despite these modifications is exceedingly rare. The caliber of suture should be the smallest possible to line up the tissue, which is typically not under tension. There was no local or systemic toxicity except for an occasional ecchymosis or bruise at the injection site (Rehman et al, 1998). There are myriad reasons for this failure to address the issues; an important example is failure of the physician to broach the subject with the patient (MacLaren, 1995; Sadovsky et al, 2006; Sobecki et al, 2012). This definition intentionally includes a degree of diagnostic conservatism and flexibility. In some cases, a repair of the lateral curvature can be approached through a small incision at the point of maximal curvature. Circadian variation in testosterone, sex hormone-binding globulin, and calculated non-sex hormone-binding globulin bound testosterone in healthy young and elderly men. Approximately 50% of circulating T in premenopausal women is produced by the adrenal glands with the remaining 50% produced by the ovaries (Judd et al, 1974). Progression detection of stage I nonseminomatous testis cancer on surveillance: implications for the followup protocol. The last consideration is of least importance but has strongly influenced opinion regarding the optimal treatment of these patients. Without novel diagnostic markers, neither biochemical nor clinical parameters alone are sufficient for identifying affected individuals. In the same double-blind placebo-controlled study mentioned previously, Safarinejad and colleagues compared the effects of L-carnitine with placebo (Safarinejad et al, 2007). Overall treatment results were subjectively scored as acceptable in spite of limited curvature improvements, which varied from "no change" to "mild improvement.

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Although activation of these particular areas is of great interest, further studies are necessary to understand completely the neurobiology of orgasm, ejaculation, and sexual satisfaction in men (Table 26-7). This approach was first described by Fadel and associates (2000) in 18 patients who had simultaneous resection of masses located in the retroperitoneum and lower mediastinum. One metric of whether infertility is exerting an adverse psychological effect on the male is frequency of intercourse, which may be altered in up to half of men being treated for infertility and is associated with libido and sexual satisfaction (Ramezanzadeh et al, 2006). Systemic absorption of vaginal estrogen preparations is generally very low (Weisberg et al, 2005; Simon et al, 2010; North American Menopause Society, 2013) and hence local therapy may be preferable for patients and providers who are concerned primarily with genital effects. Impact of diabetes mellitus on the severity of erectile dysfunction and response to treatment: analysis of data from tadalafil clinical trials. With the nodal packet circumferentially dissected except for its attachments to the saphenous arch, venous tributaries are clipped. Bilateral increased apoptosis and bilateral accumulation of cadmium in infertile men with left varicocele. The relative importance of overall epididymal contact time versus region-specific maturation to gains in mature sperm motility patterns is unknown. Randomized, placebo-controlled, double-blind, parallel design trial of the efficacy and safety of Zestra in women with mixed desire/interest/arousal/orgasm disorders. Phase 1 prospective evaluation of the oncological adequacy of robotic assisted video-endoscopic inguinal lymphadenectomy in patients with penile carcinoma. Higher ejaculatory duct pressures have been directly measured in men with ejaculatory duct obstruction (Eisenberg et al, 2008). This will be more extensive after external-beam radiotherapy because of the larger treatment volume. Recording from the penis is considered to be a potentially useful method of testing penile autonomic innervation (Daffertshofer et al, 1994). Chiang and colleagues (1992) postulated that a decrease in the elastic fibers of the tunica albuginea and an alteration in the tunica albuginea microarchitecture may contribute to impotence in some men. Among four series reporting specifically on the T1 grade 2 subset, in 129 initially node-negative patients, metastases occurred in 18 (14%) (see Table 37-8). Ideally, operating room traffic should be minimized, and laminar flow ventilation should be used to reduce surgical site infection further. This nomenclature has served to separate carcinoma in situ from the mainstream of thinking and reporting of penile carcinoma. If clinically significant ejaculatory ductal obstruction is suspected and if the position of the obstruction is amenable to surgery, treatment is surgical resection. It can also trigger scar remodeling; it has been shown that tension applied to tissues leads to a reorientation of collagen fibrils parallel to the axis of stress (Molea et al, 1999; Shapiro, 2008) these changes are the result of a process referred to as mechanotransduction whereby mechanical stimuli are converted into chemical responses within the cell (Alenghat and Ingber, 2002). In the bulky cauda epididymis, the tubule diameter enlarges substantially and acquires an irregular shape. These other assessments include radiographic imaging after injection of contrast directly into the seminal vesicles, or vesiculography; aspiration of the seminal vesicles to determine whether sperm is present; and injection of diluted indigo carmine or methylene blue dye into the seminal vesicles and observation by cystoscopy of whether the colored dye flows from the ductal orifices at the verumontanum, a technique referred to as chromotubation (Purohit et al, 2004). Several questionnaires have been proposed for use in screening, particularly with respect to hypogonadism (Morley et al, 2000; Daig et al, 2003; Heinemann, 2005). Management of sexual dysfunction in patients with cardiovascular disease: recommendations of the Princeton Consensus Panel. A and B, Urethrography in a patient with urethral stricture disease associated with lichen sclerosus. Traumatic laceration of intracavernosal arteries: the pathophysiology of nonischemic, high flow arterial priapism. High-dose testosterone therapy may result in improved spermatogenesis, but data on this form of treatment are limited (Tordjman et al, 2014). Is the association between balanitis xerotica obliterans and penile carcinoma underestimated Adjuvant and neoadjuvant vincristine, bleomycin, and methotrexate for inguinal metastases from squamous cell carcinoma of the penis. In most contemporary series, the open conversion rate is less than 5%, but it has been reported as high as 11. Balanitis, or inflammation of the glans, can occur as a result of poor hygiene, from failure to retract and clean under the foreskin. Suture ligature should be avoided in the arteries to the bulbospongiosum because of their proximity to the nerves as they are coursing into the corpora cavernosa. Intracavernous administration of an -adrenergic agent should contract cavernous smooth muscles, allowing sinusoidal blood to egress from subtunical veins.


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Expression and activity of heme oxygenase-1 in artificially induced low-flow priapism in rat penile tissues. A person may identify as transgender without using cross-gender hormonal replacement or having gender reassignment surgery (Persson, 2009). The plane between the mesentery and the retroperitoneal fat is developed by identifying the gonadal vein and developing the plane along its anterior surface. For screening purposes, measurement of total serum testosterone level is generally sufficient. Three of 6 patients with recurrence (50%) either died or developed distant metastases. Long-term followup of penile carcinoma treated with penectomy and bilateral modified inguinal lymphadenectomy. In their series, men with idiopathic ischemic priapism longer than 20 hours showed no detectible cavernous arterial inflows. Evaluation of arteriogenic impotence with intracorporeal injection of papaverine and the duplex ultrasound scanner. Brief report: testicular and ovarian resistance to luteinizing hormone caused by inactivating mutations of the luteinizing hormone-receptor gene. Outcomes reported in several retrospective desperation series are listed in Table 35-6 (Donohue et al, 1998; Ravi et al, 1998; Albers et al, 2000). Whether the holmium laser is better than the cold knife can be debated; the hot knife is unnecessary. The rates of retrograde ejaculation have been consistently low with the laparoscopic approach and range from 0% to 14% (Albqami and Janetschek, 2005; Neyer et al, 2007; Nielsen et al, 2007; Cresswell et al, 2008; Skolarus et al, 2008; Steiner et al, 2008). The external spermatic fascia is closed with interrupted 5-0 Vicryl, facilitated by the previously placed suture at the apex of the external spermatic fascia. Women who report dissatisfaction with one lubricant should be encouraged to investigate alternatives (Queen, 2013). These disease relationships include epilepsy (Keller et al, 2012b), sensorineural hearing loss (Keller et al, 2012a), open-angle glaucoma (Chung et al, 2012a), urinary calculi (Chung et al, 2011), psoriasis (Chung et al, 2012b), atopic dermatitis (Chung et al, 2012d), chronic periodontitis (Keller et al, 2012d), viral hepatitis (Chung et al, 2012c), varicocele (Keller et al, 2012c), and gastric ulcers (Keller et al, 2012e). Cryptorchidism the basis of cryptorchidism and the relationship of the disorder to male reproductive function is detailed in the section of this chapter describing childhood diseases in the reproductive history of the infertile male. Patients on chronic medical therapy to decrease the frequency of stuttering episodes may significantly benefit from performing a single sympathomimetic intracorporal injection at home as part of a personal treatment algorithm (Virag et al, 1996; Teloken et al, 2005). Smooth muscle has neither a T-tubule system nor a welldeveloped sarcoplasmic reticulum. Radiation may be the only solution for a patient with significant comorbidities who is not a surgical candidate. Strategies to preserve penile size after prosthetic implantation can be implemented before insertion, intraoperatively, or after insertion. In addition to its influence on sexual function, other physiologic changes such as fatigue, muscle wasting, osteoporosis, and changes in pain were also observed (Aloisi et al, 2009). Androgen-dependent nitric oxide release in rat penis correlates with levels of constitutive nitric oxide synthase isoenzymes. However, the relationship between T and sexuality in women is inconsistent (Davis et al, 2005; Brotto et al, 2010). Dihydrotestosterone is the active androgen in the maintenance of nitric oxide mediated penile erection in the rat. The symptoms were severe enough that the individuals avoided ejaculating to try to prevent the symptoms. Psychosexual functioning of partners of men with presumed non-organic erectile dysfunction: cause or consequence of the disorder The value of sildenafil as mode of stimulation in pharmaco-penile duplex ultrasonography. Surgeries such as transurethral resection of the prostate and minimally invasive therapies for prostatic enlargement are associated with ejaculatory dysfunction (Jaidane et al, 2010; Elshal et al, 2012). The adrenergic innervation of the vas deferens and the accessory male genital glands. Effect of smoking on the functional aspects of sperm and seminal plasma protein profiles in patients with varicocele. The vein gathers blood from the emissary and circumflex veins, and passing beneath the pubis at the level of the suspensory ligament, it leaves the shaft of the penis at the crus and drains into the periprostatic plexus.

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Testis cancer cells have a genetic determination for a high sensitivity to apoptosis inducing stimuli. Simultaneous microsurgical vasal reconstruction and varicocele ligation: safety profile and outcomes. Symptomatic retroperitoneal lymphoceles are extremely rare with reported rates ranging from 0% to 1. Slaton and colleagues (2001) found that describing the percentage of poorly differentiated cancer in the primary penile tumor specimen correlated with lymph node metastasis. The median duration of response was 16 weeks with an overall survival of 28 weeks (Haas et al, 1999). Spontaneous resolution of these masses is reported in 50% to 60% of cases, and the median time to resolution is 13 to 18 months (Flechon et al, 2002; De Santis et al, 2004). Similar patients with palpable nodes on initial presentation should undergo fineneedle aspiration cytology. Further studies have suggested that these adverse effects can be modified by cotreatment with other drugs such as sildenafil (Fava et al, 2006) or mianserin (Aizenberg et al, 1997). A statement by the working group on endothelins and endothelial factors of the European Society of Hypertension. The determination of whether a "G spot" exists is something of an academic question. Tumor marker levels in post-chemotherapy cystic masses: clinical implications for patients with germ cell tumors. PostmortemSpermRetrieval Postmortem sperm retrieval and cryopreservation (but no pregnancies) were initially reported by Rothman in 1980 and involved removal and mincing of the epididymis. Awareness of cultural paradigms is useful; however, individual women may not conform to stereotypes of their culture. Severity of erectile dysfunction at presentation: effect of premature ejaculation and low desire. The first and largest of these plexuses is the celiac plexus, which contains paired ganglia that lie lateral to the celiac artery. Ultimately, the castrated epididymis loses the ability to sustain sperm motility, fertility maturation, and sperm storage capacities, processes that are reversed with androgen replacement. Newborn priapism is an extremely rare phenomenon with only limited case reports and rare application of contemporary diagnostic modalities. After the epididymis has been dissected off the testis and flipped up, a two-stitch end-to-side intussusception anastomosis is performed as described earlier. Traction therapy for men with shortened penis prior to penile prosthesis implantation: a pilot study. Similarly, the patient-reported outcome measures showed an improvement in the acupuncture and paroxetine groups. Androgenization should therefore be assessed by laboratory evaluation in all men presenting for infertility including those in whom sperm density is greater than 20 million/mL. Priapism: report of case in a clinical study of the literature with reference to its pathogenesis and surgical treatments. Moderate and severe late gastrointestinal toxicity (usually chronic dyspepsia or peptic ulcer disease) is reported in 5% and less than 2% of patients, respectively. Objectively, a decreased plaque volume of more than 50% was noted in 30% of the subjects. If functional reconstruction is deemed reasonable, we have employed an above-and-below technique, in which laparotomy is combined with a posterior perineal triangle dissection. Testicular and epididymal percutaneous sperm aspiration in men with either obstructive or nonobstructive azoospermia. Although the ejaculatory duct contains an outer muscular layer in its extraprostatic and intraprostatic segments, as the duct courses distally the outer muscular layer dissipates, and there is no valvelike, muscular "sphincter" at the ejaculatory duct orifice, as was once thought (Nguyen et al, 1996). Semen cryopreservation in pubertal boys before gonadotoxic treatment and the role of endocrinologic evaluation in predicting sperm yield.

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The exact amount of time that sperm can remain fertile within the epididymis is unclear, but animal studies have shown that sperm can remain viable for several weeks after vas deferens ligation (Hammond and Asdell, 1926; Young, 1929). Gene therapy of erectile dysfunction in the rat with penile neuronal nitric oxide synthase. Testicular cancer: marked birth cohort effects on incidence and a decline in mortality in southern Netherlands since 1970. A meta-analysis of cryptorchidism studies reported that the contralateral descended testis is also at slightly increased risk (relative risk 1. Failure is usually the result of preservation of the periarterial plexus of fine veins (venae comitantes) along with the artery. Functional properties of afferent fibers supplying reproductive and other pelvic organs in pelvic nerve of female rat. However, we and others have extensive experience with these flaps and, in select cases, have had very good results. Epidemiologic studies have shown strong associations of MetS and its individual components with increased risks of developing a host of benign and malignant urologic diseases. A patient with genital lymphedema can readily undergo reconstruction with either a split-thickness skin graft or, in select cases, the lateral margins and the posterior margins of the scrotum. Subsequent follow-up at 3 months, 6 months, and then annually should be scheduled to assess healing, particularly cylinder tip position in the glans; device functioning; and patient satisfaction. In this position, a sudden "faux pas de coit" or missed thrust may lead to high intracorporeal pressures (Bitker et al, 1988). Long-standing cases with a long length of urethral stricture are amenable to techniques of reconstruction but are very challenging. The patient should understand that the goal is to make the penis "functionally straight," which expert opinion defines as a residual deformity of 20 degrees or less (Ralph et al, 2010; Levine and Burnett, 2013). The estimated penile length loss can be determined during preoperative testing while the penis is erect by measuring the difference in length between the long and short sides of the penis. The perineal body receives fibers from the anterior portion of the anal sphincter and is the central point of insertion of the superficial transverse perinei muscles that arise at the ischial tuberosities. Repeated successful induction of fertility after replacing hydrocortisone with dexamethasone in a patient with congenital adrenal hyperplasia and testicular adrenal rest tumors. Some of the sensory branches, however, are commonly sacrificed in the regional node dissection. Except for the endpiece region, the sperm is enveloped by a highly specialized plasma membrane that regulates the transmembrane movement of ions and other molecules (Friend, 1989). The three main sources of cholesterol in the Leydig cell are (1) external, from blood-borne lipoprotein and internalization of cholesterol-lipoprotein receptor complexes, (2) de novo synthesis from acetate, and (3) stored cholesterol esters in lipid droplets. Both surgeon and assistant should be comfortably seated on microsurgical chairs that stabilize the chest and arms. When practically discussing testis malignancy, the three significant nodal regions are the left paraaortic, interaortocaval, and right paracaval. Current and future testosterone delivery systems for treatment of the hypogonadal male. For example, although hamster and rabbit sperm are in general immotile within the caput epididymis, motile sperm are found in this region (albeit developing motility far more slowly and persisting for shorter periods than in the normal system) after epididymal duct ligation within the corpus region (Orgebin-Crist, 1969; Horan and Bedford, 1972). Female sexual dysfunction among young and middle-aged women in Hong Kong: prevalence and risk factors. Hence women with a sexual pain disorder may be able to experience sexual pleasure and bonding with a partner by means of clitoral stimulation. If inguinal adenopathy is present, radical node dissection is advised (Hagan et al, 1975) but prognosis is poor (Yang et al, 2005). Ejection is mediated by somatic nerves (S2 to S4), and involves pulsatile contractions of the bulbocavernosus and pelvic floor muscles together with relaxation of the external urinary sphincter. A similar report from Uganda documented partial or complete tumor regression in 45% of treated patients (Kyalwazi et al, 1974).

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Most patients experience recurrence within the primary landing zone (McKiernan et al, 2003; Heidenreich et al, 2005). If formal vasography was performed, the hemivasotomies are carefully closed using microsurgical technique. In the normally flaccid penis, electrical activity is described as exhibiting a rhythmic slow wave with intermittent bursts of activity. It is important to note that immune modulators and antiviral agents have the potential to affect the viral load. Of 323 patients in this study with 611 clinically negative groins, six such recurrences were noted, all within 15 months. At our center, we perform neonatal circumcision with a penile block for anesthesia. The vas deferens receives its blood supply from the deferential artery, a branch of the superior vesical artery. Steroids should not be used empirically for the management of any sexual pain disorder without a diagnosis. Pathologic features of epidermoid carcinoma of the penis: a prospective study of 66 cases. There are several disadvantages to the use of a forearm flap for phallic construction. Although coitus-associated orgasms may be physically possible but inhibited in some women, there is no reliable data indicating that women who rely on stimulation of the glans clitoris for sexual climax are abnormal (Colson, 2010). Mechanism, assessment, and incidence of male infertility after inguinal hernia surgery: a review of the preclinical and clinical literature. It is ideal to anticipate the need for aortic replacement preoperatively to allow proper patient counseling and time to coordinate between surgical services. Clinical studies of calcium channel blockers have demonstrated no adverse effect on erection; ejaculatory complaints, which may be due to decreased force of bulbocavernous muscles, seem short-lived (Suzuki et al, 1988). The detailed description of distinct templates based on the laterality of the testicular primary was the first of its kind and set the stage for further refinement. Respect for human rights warrants that a person with mental disability should not be denied the right to sexual pleasure (Greenspan, 2002); at the same time, issues of consent and coercion are difficult to resolve in persons with cognitive impairments (Spiecker and Steutel, 2002). In the penis, the lymphedematous tissue can be excised by removing the dartos fascia and skin, dissecting in the layer immediately superficial to Buck fascia. A congenital lateral curvature of the penis is often associated with some complexity of curvature; patients frequently notice lateral curvature in association with a ventral or, less commonly, a dorsal curvature. This should be done before injection with indigo carmine or x-ray contrast material (Sheynkin et al, 1999b). Prognosis of primary mucosal penile melanoma: a series of 19 Dutch patients and 47 patients from the literature. Processes 1 and 2 require efferent neurologic input from the L1 through L4 postganglionic sympathetic fibers, which coalesce with their contralateral counterparts in the superior hypogastric plexus. Observation of liver lesions is warranted in some cases, particularly when hepatic involvement may require extensive resection. In addition, he reported that this node (subsequently termed the Cabanas node) was positive in 4% of patients in whom the lymph nodes were not deemed clinically suspicious. When the side of primary tumor is completed with the templates described, a small amount of tissue is left just medial to the contralateral ureter and inferiorly toward the common iliac vessels. Equivalence of three or four cycles of bleomycin, etoposide, and cisplatin chemotherapy and of a 3- or 5-day schedule in good-prognosis germ cell cancer: a randomized study of the European Organization for Research and Treatment of Cancer Genitourinary Tract Cancer Cooperative Group and the Medical Research Council. Regulation of molecular traffic also occurs at the level of capillary endothelial cells. Should questionnaires of female sexual dysfunction be used in routine clinical practice An investigation of sexual dysfunction in female partners of men with erectile dysfunction: how interviews expand on questionnaire responses. Herniorrhaphy with polypropylene mesh causing inguinal vasal obstruction: a preventable cause of obstructive azoospermia.

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